Abstract
It is rare for a book review to start with the sentence “I loved this book.” I am, however, going to take the liberty of starting this review with exactly that sentence. I loved this book. What a useful and lovely idea Robert Winer and Kerry Malawista had when they envisioned this project! They asked twenty-five analysts to answer a set of thirty-two questions they had put together for an interview with each analyst. Only twenty-one agreed to take part. After the interviews were transcribed, two subjects felt that too much was exposed in their interview and asked asked that it not be printed. Two others were not included for reasons not shared with us. Thus, the book contains seventeen interviews, with eleven male analysts and six female analysts, from the U.S. and several other nations.
Why did Winer and Malawista take on this project? They wanted, it seems, to explore various questions posed in their introduction: “What is it like to be a working psychoanalyst? . . . What do analysts experience in the course of meeting with their patients? How do they think about what they are doing? What is it like for them to take account of themselves? . . . To feel appreciated and then to feel devalued? To feel betrayed? To try to find ways to do what’s possible? To feel responsibility for someone’s life while working to maintain your own balance?” (p. xv).
Another reason is their realization that often in psychoanalysis case presentations are “so impersonal”: “neither the patient nor the analyst comes to life. . . . it’s consistently hard to get a sense of what this person would be like for the analyst to sit with beyond the broad categorical framing (the patient is demanding, or insatiable, or self-demeaning, or argumentative, or competitive). It is virtually impossible to get a feel for what it would be like to be a patient with this analyst. This book is an effort to open that up” (pp. xvi–xvii). And what a beautiful job it does of accomplishing this. Kudos to these editors.
Each interview is followed by the comments by the editors. The interviewees include Stefano Bolognini from Italy, Ilany Kogan from Israel, and Rosemary Balsam, Joseph Lichtenberg, Salman Akhtar, Nancy McWilliams, Nancy Chodorow, Richard Waugaman, Donald Moss, Jane Kite, and Jay Greenberg from the U.S. Also included are interviews with David Tuckett from the U.K., Raquel Berman from Mexico, Gerhard Schneider and Werner Bohleber from Germany, Abel Fainstein from Argentina, and Claudio Eizirik from Brazil. I found myself absorbed in, and informed by, each of the interviews, along with the editors’ comments. Some interviews touched me particularly deeply; others left me much to ponder.
I particularly enjoyed the interview with Stefano Bolognini. Bolognini talks about his analytic training, during which he had to travel two hours each way, nearly every day, for sessions with his training analyst. When Kerry Malawista asks him, “How did you do that?” Bolognini responds, “Difficultly, but I appreciated the fact that on the train one can read, one can think” (p. 2). What a response, and what an example for candidates in analytic training today. Bolognini also teaches us very beautifully in this interview his particular way of thinking about the concept of empathy, which is very different from Kohut’s. In some analyses, he says, the analyst must learn to recognize parts of a patient he does not appreciate, or even hates. He is referring here to narcissistic and destructive parts of a patient that may represent an identification with “bad objects” (p. 3); unless the analyst recognizes these parts of the patient and points them out as difficult and unlikeable, the patient will not change. “In such a case,” he insists, “one has to face the enemy” (p. 4; emphasis added).
I was glad to read Bolognini’s thoughts about acknowledging with a patient those moments when the patient has made a significant improvement, or is able to do something he or she was unable to do before (e.g., cry on the couch), as a step forward. I have found this useful in my own analysis and continue to do in a thoughtful way with my patients. When we, as analysts, are direct about the ways a patient is stuck, or is struggling with something, why would it not be important to acknowledge also when an internal struggle within the patient shows signs of improvement and forward movement? I was a bit surprised, then, by the editors’ comment that though they appreciate Bolognini’s advice, “This appears nowhere in our operational manual!” (p. 19). If that is indeed so, it is a loss. That recognizing or acknowledging a patient’s progress endangers the analysis, that it will make the patient try too hard to please the analyst by seemingly doing better, is an incorrect idea. In my experience, patients are generally trying to please their analyst anyway. It does not matter what the analyst does or does not do: patients will from time to time try very much to please their analyst. This is simply something for analysts to recognize and talk about with their patients. This fear should not prevent the analyst’s recognizing and acknowledging times when the patient has taken an important step forward as a result of their collaborative work.
In another part of this interview, when the editors ask what sort of experiences with a patient might have made him very angry during a session, Bolognini responds that he is aware that those are moments when he feels he is speaking not really with the patient but with “an internal object of the patient”
(p. 11). He clarifies that what he means is that in these situations he is dealing with someone who was part of the patient’s life at one point and is now part of the patient’s internal life but not truly introjected. “He is in the stomach of the patient, this person was not digested, it’s occupying the internal space of my patient, and for some reason, this presence was able to conquer the majority in the parliament of the patient. I am dealing with this sort of tyranny, of a dictator. That substitutes for the real self of the patient” (p. 11). What a beautiful explanation of moments and experiences in an analysis that often leave us bewildered, pained, angered, and confused.
Winer and Malawista have interviewed a number of analysts who work with patients with very serious difficulties. These analysts include, but are not limited to, Richard Waugaman, Abel Fainstein, Claudio Eizirik, Salman Akhtar, and Werner Bohleber. The interviews with these analysts are beautiful reflections, not just of their theory and technique, but also of their lives and personalities, factors bearing heavily on the good work they do with very seriously ill patients—work requiring tolerance, dedication, deep understanding, and a certain talent and analytic giftedness. It is not work that all of us can do well.
There are other gems in this book. I was particularly taken, for instance, by Rosemary Balsam’s description (p. 64) of how she dealt with the colon cancer she was diagnosed with in 2009. She decided to tell the candidates who were her patients about this right away; she felt they needed to know before she told colleagues at her institute so that her analysands would hear the news from her, rather than from others. Candidate analysands “are so involved with you,” she says, “and they are in the middle of these transferences and they are terrified anyway that something is going to go wrong with you, so I wanted to meet it up front and say this is what happened” (p. 64). She shares that she later heard from these patients that they felt that it had been a very good way to proceed. I have written quite a bit about this topic, of how useful it was for me when my analyst shared an important detail about a personal issue that was affecting his life and would potentially affect his work with me, and of events in my life that I have brought up with patients as needed. In following those patients over time, I have had the same experience that Balsam reports: it was ultimately enriching for the analyses, although it was very clear to me that patients could not react fully to the difficulties in my life when I first announced my problem. Many reactions were not available to them at that point, and expressions of those that were available were blunted until I got to a point in my life where they felt I was in safe harbor. They could then talk about their ambivalence toward me and their rage at me, whereas in the early stages they could speak only of their concern for me (Abbasi 2014).
Joseph Lichtenberg’s interview was particularly interesting for me, from details of his early life to talking about the loss of his first analyst, a woman he found to be very helpful but who died, still quite young, three years into his analysis. Lichtenberg talks about then going to Hans Loewald for a training analysis and about what a difficult experience that had been. Later in the interview he discusses the idea that people around him had developed a significant idealizing transference toward Loewald. Many of his peers who were in analysis with Loewald would tell him about the terrific things he was communicating to them, but Lichtenberg himself found Loewald not at all helpful. Finally he found another training analyst, who was “much wiser” (p. 97). Lichtenberg tells another wonderful story, about a patient who, after much improvement, started meeting with him only once every two weeks for the last year, citing her travel for work and other reasons. He makes a wonderful intervention in one session: “We are going to have to stop not meeting like this” (p. 99). This intervention, and the therapeutic dyad’s understanding of it, gradually led to her being able to terminate with him.
A few matters come up in these interviews that I found disturbing. Both Rosemary Balsam and Ilany Kogan talk, in different ways, about dealing with patients involved in child abuse. Kogan referred the patient who presented with this problem to a specialist in such issues, preferring not to deal with the issue of reporting him and feeling she could not really work with his problem. Balsam describes her patient, seen many, many years ago, and talked about how she tried to help the patient, who was hitting her child. This is a problem in psychoanalysis that I think we should consider in new and different ways. I have often heard senior analysts say that under such circumstances, though legally it is the duty of clinicians to report child abuse, analysts need not honor this obligation and indeed should not, lest people abusing their child be dissuaded from seeking the analytic help they need. I was always skeptical about this reasoning and now do not agree with it at all. Having practiced for a few decades now, I feel strongly that as analysts we should not play god, should not assume that we are above the law, and should not arrogate to ourselves a power we in fact do not possess. From much that we have seen in recent news and in our culture generally, and from a lot that I have heard from patients, it should be clear to all of us that a child who is beaten suffers a great deal. We need to reconsider the steps to be taken with patients who come to us looking for help and acknowledge, at the outset or during the course of treatment, that they are physically or sexually abusing a child. Emotional abuse is hard enough for children but can be intervened with, perhaps more effectively. But physical and/or sexual abuse is so destructive and damaging to children that interrupting it in a timely manner is extremely important. How this might be done while keeping the family somewhat intact and not handing things over to a complex, often dysfunctional social work or legal system certainly needs to be thought about. By the same token, we need as analysts to seriously question the idea that we are above the law and above the accepted norms for clinicians (we are not); it is not okay for us to not intervene as any clinician would upon hearing of a child’s being seriously abused.
Kogan’s wonderful work in Israel in an atmosphere of war and terrorism, as documented in her interview, is impressive. Her evolving thinking about the interplay between external and internal reality for people living in Israel gives us much to think about. She speaks about how, when she had grandchildren and realized what they would have to do if there was ever a chemical attack, she was better able to appreciate the concerns of a patient who, during a tumultuous period in Israel, wanted to leave the country to protect his children. How much life teaches us (if only we are willing to learn) that can then benefit our patients!
Jay Greenberg’s interview also gave me a lot to think about. I was particularly struck by this remark: “I have always thought that the cliché that people become analysts because they need to cure their mothers was half a sentence. They go into analysis because they needed to cure their mothers and they failed, and I think that if that failure is repeated in their own analysis, it can really lead to an embitterment that just gets lived out” (p. 287; emphasis added). He is talking about how, when people with such a history enter the psychoanalytic profession, if they have a terrible experience in their own analysis, they often give up professionally and have serious personal problems. He shares with us that he had a bad analysis that for a while made him behave in a mean way with his patients; kindness in analysis was something that “got beaten out of me in one of my analyses” (p. 287). He tells us that it was only in a later analysis that he was able to get help that showed him that an analyst could be both kind and analytic at the same time. It is sad to think that many analysts have had to arrive at this truth only after great suffering, and only after having more than one analysis.
In conclusion, I am indebted to Winer and Malawista for putting together this superb collection of interviews, from which experienced clinicians, early career mental health professionals, and graduate students will learn a great deal. I will in fact be sharing this book even with undergraduates with an interest in psychoanalysis. The interviews collected here provide inspiring insights into how and why these analysts became the analysts they are today, and how they are able to help their patients.
